Back
Frequently Asked Questions
What you should know about coverage information
The information provided below is not a guarantee of coverage or payment. Providers must follow documentation and billing requirements of the payer. Coverage and reimbursement decisions are made by individual plans following receipt of claims from providers. Coverage, reimbursement amount, and administration fee may vary, including by payer, plan, and patient.Product Group
mRESVIA®
Medicare Part D (pharmacy benefit) covers Food and Drug Administration (FDA) approved adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) with a $0 copayment or deductible when administered at an in-network provider.If the RSV vaccine is not on the formulary yet, a coverage exception request may be made [1].
Generally, the Affordable Care Act (ACA) mandates that non-grandfathered private health plans must provide coverage for vaccines prescribed consistent with Advisory Committee on Immunization Practices (ACIP) recommendations, without cost-sharing when patients access vaccines from an in-network provider.
The Inflation Reduction Act (IRA) requires state Medicaid agencies and Medicaid managed care organizations to provide coverage for ACIP-recommended adult vaccines with no cost sharing as of October 1, 2023.Check with your state Medicaid agency or Medicaid managed care organization for specific coverage and billing requirements unique to your state.
Most Medicare patients will access RSV vaccines through their Medicare Part D pharmacy benefit. Health care providers who want to administer RSV vaccines should confirm they can bill the patient's Medicare Part D plan or arrange for the patient to receive the vaccine through an in-network pharmacy or other in-network provider.Medicare Part B does not cover RSV vaccines such as mRESVIA®.
If you prefer to print out the information to share with your team, you can access the mRESVIA® coding sheet here.